MEDICARE: EMMANUEL VENTURES LIMITED LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	RTP.022607100-03	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2136201	OTHER		PK

General Provider Information

NPI Number	:	1053667204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMMANUEL VENTURES LIMITED LLC

Provider Business Mailing Address
First Line	:	4127 E 131ST ST
Second Line	:	MILES SUPERMARKET
City	:	CLEVELAND
State	:	OH
Zip	:	44105-5563
Country	:	US
Telephone Number	:	216-691-2369
Fax Number	:	216-691-3119

Provider Business Practice Location Address
First Line	:	4127 E 131ST ST
Second Line	:	MILES SUPERMARKET
City	:	CLEVELAND
State	:	OH
Zip	:	44105-5563
Country	:	US
Telephone Number	:	216-691-2369
Fax Number	:	216-691-3119

Authorized Official
Title or Position	:	PHARMACIST IN CHARGE
Name	:	OPEYEMI ADEWESO
Credential	:	RPH
Telephone Number	:	216-691-2369

Provider Enumeration Date	:	07/25/2012
Last Update Date	:	03/30/2017

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Directions to “EMMANUEL VENTURES LIMITED LLC ” Practice Location

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